Purpose: Evidence is increasing for effective virtual reality therapy for motor rehabilitation for children with Cerebral Palsy. We assessed the feasibility of a virtual reality therapy mode of intervention, appropriateness of measures, and potential cost-effectiveness. Methods: A 12-week, 2-group, parallel-feasibility trial (ISRCT 17624388) using Nintendo Wii Fit^TM at home. Children aged 5–16, with ambulatory Cerebral Palsy, who were able to follow simple instructions were randomised to two groups; one supported by physiotherapists (individualised activity programme), the other unsupported with children having free choice (control). Children were assessed in clinic at baseline, week 6, and week 12 by blinded assessors. Feasibility of the intervention was assessed via recruitment, adherence, and usefulness of measurement tools. Results: Forty-four children were eligible (out of 48 approached): 31 consented, 30 were randomised, 21 completed the study; 10 in the supported group and 11 in the unsupported group. Nine children discontinued from tiredness, after-school activities, homework, surgery, technical difficulties or negative system feedback. The supported group completed 19 of 36 (IQR 5-35) possible sessions; the unsupported group 24 of 36 sessions (IQR 8-36). Gross Motor Function Measure scores varied by Cerebral Palsy severity after the intervention. There were no adverse events. Conclusion: Virtual reality therapy offers potential as a therapeutic adjunct for children with Cerebral Palsy, warranting substantive confirmatory study. Gross Motor Function Measure, with modifications to improve sensitivity, appeared appropriate as a primary measure, with Timed up and Go test secondary. The intervention was inexpensive costing £20 per child. An explanatory trial to evaluate the clinical/cost-effectiveness of commercial system virtual reality therapy is feasible with minor methodological adaptation.

Objectives Waiting times in the UK for an autism diagnostic assessment have increased rapidly in the last 5 years. This review explored research (including ‘grey’ literature) to uncover the current evidence base about autism diagnostic pathways and what works best, for whom and in what circumstances, to deliver high quality and timely diagnosis. Design We performed a Rapid Realist Review consistent with recognised standards for realist syntheses. We collected 129 grey literature and policy/guidelines and 220 articles from seven databases (January 2011–December 2019). We developed programme theories of how, why and in what contexts an intervention worked, based on cross comparison and synthesis of evidence. The focus was on identifying factors that contributed to a clearly defined intervention (the diagnostic pathway), associated with specific outcomes (high quality and timely), within specific parameters (Autism diagnostic services in Paediatric and Child & Adolescent Mental Health services in the UK). Our Expert Stakeholder Group, including representatives from local parent forums, national advocacy groups and clinicians, was integral to the process. Results Based on 45 relevant articles, we identified 7 programme theories that were integral to the process of diagnostic service delivery. Four were related to the clinical pathway: initial recognition of possible autism; referral and triaging; diagnostic model; and providing feedback to parents. Three programme theories were pertinent to all stages of the referral and diagnostic process: working in partnership with families; interagency working; and training, service evaluation and development. Conclusions This theory informed review of childhood autism diagnostic pathways identified important aspects that may contribute to efficient, high quality and family-friendly service delivery. The programme theories will be further tested through a national survey of current practice and in-depth longitudinal case studies of exemplar services. Trial registration number NCT04422483.

Objective UK guidelines recommend that diagnosis of autism in children requires assessment by a multidisciplinary team. With growing numbers of referrals for assessment, diagnostic services have been under increasing pressure to meet the level of need. This study aimed to explore the number of hours of professional time required to complete such an assessment based on current practice in secondary care child development centres across the UK, and from this we calculate the cost of assessment. Design An online questionnaire, using SurveyMonkey.com, was sent to 20 child development centres asking them to retrospectively record team members involved at each stage of assessment and time taken, including report writing and administration for a typical assessment. Costs were estimated based on the hourly rate for each team member, including salary, on-costs and trust overheads. Results 12 questionnaires (60%) were returned. 10 centres adopted a two-stage approach to assessment with an initial ‘screening’ clinic determining whether the child needed to proceed to full multidisciplinary assessment. Median professional time involved was 13 hours (IQR 9.6–15.5 hours). This resulted in a median cost of £809 ($1213, based on conversion rate £1 equal to US$1.5 (November 2015)), (IQR £684–£925) ($1026–$1388)). Implications This study confirms that multidisciplinary diagnostic assessment of a child with possible autism requires significant professional time, with staff costs of approximately £800 ($1200) per child. This does not include costs of intervention, parent psychological education, investigation and assessment and management of comorbidities. If growing waiting times for diagnostic assessment are to be avoided, funding for diagnostic services needs to reflect the human resources required and the resulting costs of that assessment.

AIM To determine whether asthmatic children who present to hospital with hypoxia perceive breathlessness less well than non-hypoxic presenters. METHODS A total of 27 children aged 5–16 years (mean age 10) admitted with acute asthma had recordings of oxygen saturation (Sao ₂), clinical score, forced expiratory volume in one second (FEV₁), and breathlessness score (HMP) at admission and at 5, 10, 24, 48, and 72 hours after admission. Those defined as hypoxic (Sao ₂ <92%) at admission were compared with a non-hypoxic group. RESULTS Twelve children were hypoxic at admission. Compared with the non-hypoxic group they were younger (8.6 (SD 2.8) v 11.2 (2.8) y, p = 0.02), and had greater airway obstruction (FEV₁ 32.5 (10)% v 54.3 (26)%, p = 0.0073, 95% confidence interval (CI) −36.9 to −6.6) yet had a trend towards less breathlessness (median HMP 4 v 3, p = 0.062, CI −0.001 to 2.00) at admission. The hypoxic group had a smaller change in breathlessness from admission to discharge, despite a similar improvement in FEV₁, reflected in a lower ratio of change in HMP to change in FEV₁(ΔHMP/ΔFEV₁) (median ΔHMP/ΔFEV₁0.021%⁻¹ v0.073%⁻¹, p = 0.0081, CI −0.075 to −0.016). Linear regression analysis showed a strong relation between ΔHMP/ΔFEV₁ and initial Sao ₂(p = 0.004, r = 0.54). CONCLUSIONS Asthmatic children who present to hospital hypoxic tend to perceive themselves as less breathless than non-hypoxic children. This may predispose to a future life threatening attack.